Multispecialty Groups Need “Under one Umbrella” Multispecialty Automation

A multispecialty group or practice is one in which at least two different specialties are practiced. Of course, large groups or networks may have tens or dozens of different specialties. Providers may be MDs, DOs, DPMs, DCs, PTs, PAs, NPs, RNs, clinicians, and therapists. Depending on the specialties, some may not be medical (think cosmeticians, aestheticians, and massage therapists).  

Some specialties, including but not limited to orthopedics, radiology, pain management, neurology, and physical therapy, almost assuredly treat personal injury patients (workers' compensation, no-fault, and other accident-related/attorney-involved injuries).

The mix of possible specialties and each one's particular requirements and nuances can be eclectic. Whatever the mix, ideally, the multispecialty group should be able to use a single financial/operational/analytics/clinical charting/engagement automation platform from a single, under-one-umbrella vendor, whether it offers outsourced revenue cycle management (RCM)/billing/staffing or who provides their platform for in-house use by the group.

Let's examine what's involved automation-wise on a single platform from a single vendor regarding the various aspects of a multispecialty group's needs, whether it has two specialties or twenty (or more).

Multispecialty Financial, Billing, and Revenue Cycle Management

Depending on your group's specialties, your claims include HCFA, UB, workers' compensation, no-fault, or any combination.

You might also need guarantor and family billing, cycle billing, case-specific billing, and patient responsibility billing once payers have reimbursed, as well as complete billing for self-pay patients.

But before any claims or statements are generated, you'll want your RCM service or billing platform to:

• Perform pre-appointment eligibility verifications. 
• Obtain automated prior authorizations as needed.
• Generate pre-appointment out-of-network alerts.
• Access a patient responsibility estimator to help avoid surprises later.
• Proactively avoid denials with pre-submission alerts on claims likely to be denied by their payers and with suggestions for edits.  

Insurance discovery is an often overlooked feature that can be invaluable depending on your specialties. It can uncover coverage for patients who have none listed. An accurate insurance discovery utility will find coverage for as many as 30% of patients without insurance. It's also a powerful tool when information is partially missing (filling in the blanks).

You'll operate more efficiently and fiscally responsibly when you can waterproof your revenue by protecting it as much as possible in advance, as described by using one single outsourced or in-house billing platform for everything.

Radiology, Anesthesiology, Laboratories, and Ambulatory Surgery Centers are Separate but Combined Animals

If one of your specialties includes radiology, you want to avoid fooling around with automation that almost works because your multispecialty software needs to address radiology correctly. The radiology segment of your RCM service or in-house software can be nothing less than a full-fledged RIS platform that can work fluidly with virtually any PACS.

In fact, the RIS should be used solely by stand-alone imaging centers that specialize in diagnostic and interventional radiology. It shouldn't be "sort of a RIS."

If you have anesthesiologists, you may need time unit and CRNA billing. Your RCM company or in-house system should fully support anesthesiology billing and claims.

If you need ASC billing, that's yet another layer of requirement.

Suppose laboratory billing (clinical, pathology, toxicology, genetic, next-gen sequencing) is needed. In that case, you'll want to know that your RCM company or in-house system can handle that without requiring outside assistance or interfaces. 

Claims Now and Then 

One of your "now" claims has just been created. Irrespective of the specialty involved, was it:

• Scrutinized to the best extent possible to ensure the payer won't deny it?
• Is it coded for maximized reimbursement by the payer? 
• Could it have been coded differently for better payment without over-coding? 
• Is the best possible E/M coding in place for maximized reimbursement?
• For Medicare claims, were hierarchical conditional categories (HCC) based on the patient's risk adjustment factors (RAF) coded correctly for significant additional CMS reimbursement?  
• If multiple claims exist for a single patient, were you alerted about bundling them into a single master claim (NCCI editing) to avoid denials, assuming bundling was appropriate?

Are claims being submitted just for the sake of submitting them? If so, the "throw them out there and something will stick" approach is dangerously careless for the RCM company or the in-house system to support.

In reality, many coding facets must be respected to optimize revenue while avoiding unnecessary denials. Missing any one of them means less revenue for you. 

Your "then" claims:  Okay, your claims have been submitted and hopefully scrutinized and maximized as noted. Do you sit and wait to see how they're doing? Are payers paying attention to them? Are they being worked, or are they idling in queues? Can you figure out as to when they'll be paid?

If there's real-time claim tracking by your RCM company or by you through your in-house system, an active hand can be taken to ensure your submitted claims are "in the works." You could question payers on claims they would've typically paid by now, assuming the tracking feature for doing that is available.

BTW, if working with an RCM company and assuming they do claim tracking (it's a problem if they don't), you should also have transparent, real-time viewing of your submitted claims.

A word on denials: even with an accurate pre-submission denial preventer and NCCI editing,   some "oddball" denials will still happen. That's why your RCM company should be able to edit and resubmit them within 72 hours of them being denied, or your in-house system must have an easy-to-use denial manager that displays denial reasons and suggestions for edits for you to manage those denials on the fly, essentially as they happen.

Recap: Before submitting your HCFA, UB, WC, and NF claims, you must take several precautions. Once submitted, you must observe them to ensure they're being processed. AI-driven automation, as used by your RCM company or in-house system, should support both in nanoseconds without requiring manual intervention. 

Reconciliations and Next-Up Payers

So, things are humming along, especially if everything mentioned is being followed. Now, automated processes (EDI) by your RCM company or in-house system should reconcile payments (ERAs) virtually in real-time, ensuring your insurance A/R is accurate almost to the minute.

If there are secondary or tertiary payers, those same systems should automatically and immediately submit those claims to ensuing payers in a hands-off fashion.

Then, as soon as balances become patient responsibility amounts, those same systems should perform any number of actions depending on your preferences, including generating:

• paper statements to patients
• email statements which include a link to pay online
• text balance-due reminders, which also include a link to pay online

Emails and texts should be tracked to see if they're opened. Either could generate a “red flag” call from you. Undeliverable emails or texts should automatically revert to paper. 

This is a reminder that if you had access to a pre-appointment patient responsibility estimator and obtained patient acknowledgments, their balance-due statements/emails/texts should not surprise them.

Patients are the third largest payer group in the US, behind only Medicare and Medicaid. That's because insurance payers are increasingly transferring payment responsibility to patients. 

These payment engagement tools and portals with online payment capabilities are excellent for keeping patient A/R as tightly controlled as possible. That's why your RCM company or in-house system should support all of them as user-defined options. 

Multispecialty Appointment Scheduling 

Certain specialties have particular requirements for scheduling appointments and appointment types. The phrase "multi-modality scheduling" may come to mind.

In a multispecialty setting, your scheduling requirements can - but shouldn't - be overwhelming because your RCM company's or your in-house system's scheduler should accommodate:

• a portal for patients to schedule/request appointments on-demand without disrupting staff
• batch eligibility verifications
• centralized or POS scheduling, or both
• scheduling for a single appointment for one specialty
• scheduling for multiple appointments for multiple specialties on one day or over multiple days, in one location or multiple locations
• back-to-back scheduling for related specialties (for example, an orthopedics follow-up and then physical therapy, or a dermatology/MOHS visit and then a cosmetician or Botox appointment)
• comprehensive, user-defined appointment reports and analytics
• appointment reminder texts containing information specific to the appointment, with patients able to confirm or cancel through their texts
• reminders to schedule follow-up or annual visits
• workflow by location to avoid bottlenecks
• scheduling of resources, equipment, and staff, such as technicians
• an ability for providers to access their schedules from their iOS or Android devices

It would be elementary if you only needed your scheduler to schedule appointments. In reality, your scheduler should be a powerful management and financial platform within your RCM company's or in-house system's even more expansive capabilities. Anything less would be to your disadvantage.

Multispecialty Financial and Operational Analytics, KPIs, Reports, and Dashboards

You need financial and operational data to operate successfully, make improvements where needed, and gauge how predictive analytics will go. You'll want to see where you were, where you are right now, and where you will go.

You'll want to display comparative graphs, charts, and dashboards to see about productivity, which providers are performing what procedures and producing how much revenue, the range about how much different payers reimburse for the same procedure, your payers' average reimbursement turnaround times, and why certain claims that should've been paid are still open. You might even need reports on purchasable products (more on products follows below).

If you perform anesthesiology, you may want time units and CRNA reports. 

The types of reports you need are almost limitless. Your RCM company should provide the analytics you need and have routine reviews with you. But you should also be able to compile whatever reports you want, on-demand at any time, with nothing hidden or curtained. Of course, if you use an in-house system, it should also produce user-defined reports. Either way, reports should be exportable to Excel®. 

Clinical reports are also needed! More on those follow next.

Multispecialty Electronic Health Records: an Amalgam of Encounter Types!

Clinical charting and reporting in a multispecialty setting can be unwieldy, especially when different EHRs are needed for certain specialties. Generally, it takes work to find one EHR that handles every specialty. If you can identify one that covers at least most of your specialties, and if one or two others can interface, then that is a "best of all possible worlds" solution.

If your RCM company's or in-house platform's EHR handles 20-30 specialties, you're probably in good shape. If your specialties include substance use disorders/behavioral health/psychiatry and in any level of care (IP, IOP, OP) and a clinical solution from your RCM or in-house system, that's an added benefit.

The EHR must be:

• ONC-certified and 21st Century Cures Act-capable
• able to calculate HCC and RAF for optimized billing (as described above)
• able to capture natural language conversations and turn that into data within the patient's record and for transcribing into reports, all without keyboard intervention

The more comprehensive the EHR is for most of your specialties (if not all), the more efficient you'll operate with minimized or no interfaces. 

Multispecialty Mobility and Engagement

Your RCM company or in-house platform should support several features/options to keep patients and providers engaged and mobile:

• a patient portal empowering patients to self-serve on any number of levels, on-demand at their convenience for online payments, appointments, completing forms, and editing their demographics, all without disrupting your staff
• a kiosk and document scanning with data capture to further bolster intake 
• a built-in telemedicine app (not a third party) for remote encounters and for generating revenue
• Remote patient monitoring enables you to monitor patients' vitals, from which revenue can be derived, assuming your RCM company or in-house system can generate those claims.

Capabilities such as these, which promote engagement, connectivity, mobility, patient satisfaction, efficiency, and revenue, can significantly benefit multispecialty settings.

Multispecialty Groups and Purchasable Products and Non-Medical Services

Braces, orthotics, creams, supplements, shoes, cosmetics, and more are all types of products and services commonly available for patients, especially in multispecialty settings.

You could use a stand-alone interfaced system, but if your RCM company or in-house system has a built-in (no extra cost) capability to handle products/services, so much the better. It should be able to:

• track inventory
• calculate sales tax based on location
• open a "checkout" window for payments separately from those for medical procedures or visits
• accept gift cards and coupons in addition to regular payment methods
• generate reports on purchasable products and non-medical services

Whether products and non-medical services are a large or small part of your multispecialty group, having a built-in feature for managing them works to your advantage. 

Multispecialty Groups and Attorneys

If you have personal injury patients, they no doubt have attorneys, which means you have them (the attorneys) to manage as another group mixed into your work life. 

What’s needed is a built-in (no extra cost) database for patients' attorneys cross-referenced to their clients (your patients), making it easy for you to identify patient/attorney connections. 

The Attorney Manager should be case-specific for patients with different attorneys for different incidents.

Enhancing the Attorney Manager would be an optional attorney portal empowering them to self-serve in retrieving needed information without disrupting your staff with time-consuming lookups and deliveries for which you derive no income. 

If your RCM company or in-house platform has a built-in attorney manager database and an optional portal, managing attorneys would be effortless.  

Multispecialty CRM

If your group does any marketing or advertising, you need a customer relationship manager (CRM) to track the success of those campaigns. CRMs can be very expensive, but if your RCM company or in-house system has a built-in (no extra cost) CRM capability, it will eliminate the cost and the interfacing.

That said, you should use a stand-alone CRM. If so, it should have an easy interface with your RCM or in-house system. 

Security in an Insecure World

We're ending with security and the need for every protection because, unfortunately, the bad actors are great at what they do.

Your HIPAA-compliant RCM company or in-house system vendor should have their remotely hosted servers with an ultra-secure, SOC 1 and SOC 2 certified entity that supports redundancy and the highest levels of physical protection. Ideally, whatever resource you use (1) has never had an intrusion, (2) has the technology to detect potential problems that can be stopped before they start, and (3) performs backups for you if restores are ever needed.

When protections and protocols are in place as described, you'll have peace of mind to the greatest extent possible.

End Note

Multispecialty groups have multidimensional, intricate needs on so many levels. When technology from your RCM company or in-house automation vendor can cover so much under one umbrella, you're more empowered to operate with maximum efficiency and optimized revenue.

ADSRCM, with its outsourced MedicsRCM services and staffing to help consolidate your efforts, and ADS, with its MedicsCloud Suite, if in-house automation is preferred, both support everything mentioned above. 

The ONC-certified MedicsCloud EHR, excellent for almost 30 specialties, can be accessed by ADSRCM clients and is part of the MedicsCloud Suite. Clients can also retain their existing EHRs with interfaces. MedicsRIS for radiology is a full-featured RIS if needed. 

ADSRCM and ADS use Equinix®, a SOC 1 and SOC 2-certified global leader in cloud hosting. 

Your patients are treated under one roof by providers in different specialties. Your specialties can also be served under one service or platform and by one vendor with either ADSRCM and MedicsRCM or ADS and the MedicsCloud Suite! 

Contact us at 800-899-4237, Ext. 2264 or email info@adsc.com for more about our platforms and services for helping your multispecialty setting drive revenue and efficiency.